Académique Documents
Professionnel Documents
Culture Documents
Richard A. Gardner
IPT Vol 5, 1993
Richard A. Gardner is a psychiatrist, author, publisher, and lecturer at 155
County Road, P.O. Box 522, Cresskill, NJ, 07626-0317. This selection is
adapted from his 1992 book, True and False Accusations of Child Sex
Abuse: A Guide for Legal and Mental Health Professionals. Cresskill, NJ.
ABSTRACT:
Physicians are increasingly being asked to conduct examinations to
determine if there is physical evidence that a child has been sexually
abused. Unfortunately, a common practice for many physicians has been
to form conclusions about abuse on the basis of vague physical findings
and In the absence of information outside of the fact that someone
believes the child has been abused.
Recently, however, there has been research on the characteristics of the
genitals of normal, non-abused children. This research provides the
baseline information needed to evaluate physical findings.
This research is described, the terms used in medical reports are defined,
and the physical findings which may be indicative of sexual abuse are
discussed.
[Introduction]
Up until a few years ago there was very little published in the medical
literature on the physical findings consistent with child sex abuse. There
was even less published on normal findings in non-abused children.
Moreover, there were no extensive studies on what the hymen of the nonabused child looks like. Some physicians claimed that the normal hymen
is circular and that any irregularity meant something had been inserted
into the vaginal canal. Although others maintained that there is a wide
variety of irregularities within the normal range, they were unable to
provide specific experimental data regarding the frequency of these
irregularities.
There was even controversy regarding the size of the normal hymenal
ring at various ages. Until recently, there were no extensive studies in
which measurements were taken. And even the studies that were done
were flawed by the fact that the investigators failed to consider that the
hymenal orifice varies in size with the position the child assumes when
the examination is being conducted, as well as with the degree to which
the child's legs are spread by the examiner.
adult male penis into a three-year-old girl's vagina will produce severe
pain, significant bleeding, and deep lacerations, and that the insertion of
crayons and pencils at that age is extremely rare because of the pain and
trauma that such insertion will produce.
There are significant differences of opinion regarding what is the normal
size of the hymenal opening, and this, of course, bears directly on the
question of abuse. Most experts agree that there have not been large
studies of many children at different ages with regard to what the normal
hymen looks like, its size, and whether or not it is indeed circular.
Furthermore, all agree that the older the child, the greater the likelihood
the vaginal opening will accommodate a penis without significant trauma.
Thus, by the age of nine or ten, one does not get the same degree of
trauma that is found at younger ages.
Most agree, as well, that children of nine and ten, whose vaginal orifices
are still small, could still be brought to the point of intercourse with an
adult by gradual stretching of the vagina in the course of repeated
experiences in which progressively larger objects (fingers, and ultimately
a penis) are inserted.
Some physicians believe that a certain type of dilatation ("winking") of the
anal mucosa is pathognomonic of penile penetration into the anus. There
are others who claim that such dilatation is normal. (Here I am with the
group that holds that such puckering is most often normal and is not a
manifestation of sex abuse.)
The net result of this situation is that there may be sharply divided
opinions among physicians regarding whether a particular child has been
sexually abused. However, this does not stop each side from bringing in a
parade of adversary physicians who predictably provide the "proof" that
the child was sexually abused or that there is "no evidence" of sexual
abuse. Another result of this situation is that many doctors are making a
lot of money, because providing court testimony can be quite
remunerative.
Definition of Terms
I will focus here on several terms that are often seen in reports of physical
examinations of children being evaluated for sex abuse. Because girls are
much more frequently subjected to sex abuse than boys, and because
controversies regarding the signs of sex abuse are much greater in girls
than boys, most of these comments relate to the physical examination of
girls. It is assumed that the reader has a basic familiarity with the female
genitalia and is familiar with such terms as labia majora, labia minora,
clitoris, urethral meatus (orifice), hymenal orifice, and vaginal walls.
Examination Positions
Most often there are two positions described for a girl's examination, the
supine frog-leg position and the prone knee-chest position. When
examined in the supine frog-leg position, the child is on her back with her
legs spread apart in "frog-leg" fashion. In the prone knee-chest position,
the child's abdomen is close to the table and she is supported by her
knees and chest.
McCann (1988) emphasizes the importance of the child's chest touching
the table and the child's back being in a relaxed position. Examination of
the vagina and cervix (without the use of a speculum) is more easily
accomplished in young children in the prone knee-chest position.
Sometimes a third position is utilized, the supine knee-chest position.
Here the child lies on her back, puts her legs together, flexes her thighs at
her hips, and is asked to hug her knees to her chest.
Hymenal Configurations
There are a wide variety of hymenal orifices and configurations. So great
is their variation that some orifices do not easily lend themselves into
being categorized. Furthermore, there is no strict standardization with
regard to the names of the various kinds of openings. Accordingly,
different examiners may use different names for the same hymenal
configuration. The way in which the child is positioned may affect the
hymenal configuration and thereby affect the name used by the
examiner. I describe here the most common types of vaginal orifices.
Next to each name I have placed in parentheses other terms that are
often used for the same configuration.
Annular (Circumferential, Cuff-like, Central) This is the simplest
configuration. The hymenal orifice is represented by a relatively even
circle. Basically, it is a circular hole that can vary in diameter from almost
a pinpoint to an enlarged orifice that leaves practically no hymen at all,
only a rim. The cuff-like configuration is also annular, yet there is a
thickening at the circumference of the orifice. Most competent examiners
agree that the perfect circle type of hymen is not common.
Crescentic (Horseshoe, U-Shaped, Posterior Rim, Semilunar) The
hymenal orifice is represented by a half-moon or crescent. The bottom of
the U-shape, however, is at the posterior position (closest to the anus).
The hymenal tissue, then, can appear as if it were hanging down from
above (the anterior position).
Redundant (Denticular, Folded, Fimbriated, Serrated) Here the
The term anterior is used to refer to that past of the hymen that is closest
to the front of the body, and the term posterior to that part of the hymen
that is closest to the back of the child's body. Commonly, the site of a
particular observation is described by visualizing the hymenal ring to be
like the face of a clock. Accordingly, 12:00 o'clock would be the most
anterior position; 3:00 o'clock the position closest to the child's left side
(the examiner's right); 6:00 o'clock, the position closest to the child's
anus; and 9:00 o'clock the position closest to the child's right side (the
examiner's left). There is a widespread belief that attempts to insert an
object (animate or inanimate) into the child's vagina is more likely to
produce trauma to the posterior rim of the hymen, namely, in the range
from the 3:00 to 9:00 o'clock position.
Sometimes examination of the hymen may be compromised by the
presence of labial adhesions. These cause a sticking together of adjacent
parts of the labia minora. Sometimes the attachment is by fibrous bands,
and sometimes merely by a sticking together of labial tissue. These are
so common that they are generally considered to be in the normal range.
Most competent examiners would not consider them, per se, to be a sign
of sex abuse.
Additional Terms
Here I define further terms frequently seen in reports by examiners
assessing for sex abuse.
Labial adhesions This term refers to the "sticking together" of the labia
minora and/or labia majora. Other names for the same phenomenon
include labial agglutination, vulvar fusion, vulvar synechiae, gynatresia,
coalescence of the labia minora, and occlusion of the vaginal vestibule.
Labial adhesions are usually seen between the ages of two months and
seven years. They are generally considered to be the result of poor
hygiene, a mild vulvitis, or mechanical irritation along with
hypoestrogenism (McCann, Voris, & Simon, 1988).
Synechiae This refers to a pathological union of parts. It is synonymous
with the word adhesion. It is best viewed as a sticking together of parts
that should be separate from one another. Infection and irritation can
cause synechiae.
Posterior fourchette A fold of mucous membrane just inside the point
of posterior conversion of the vulva (labia majora).
Examining Instruments
Because the hymenal structures are so small (the average normal
he or she has never seen. I am certain that the same doctor would be
very reluctant to write any other diagnosis in a chart regarding a person
who was not directly examined.
The failure to get information from available alleged perpetrators has
caused much unnecessary grief. I cannot criticize such physicians
strongly enough. Although state laws generally require the physician to
report suspected abuse, they do not prevent the physician from speaking
with the alleged perpetrator before making a final decision regarding
whether a referral and investigation are warranted. Furthermore, many of
these physicians do not appreciate the degree of ineptitude of the
"validators" to whom they are referring their patients. They seem to be
operating under the delusion that these people are competent in the area
of differentiating between true and false sex abuse accusations.
As physicians they are sworn to subscribe to the Hippocratic oath in which
they vow that they will "above all do no harm" to their patients. There is
no question that many of the children who are referred to child protection
services, evaluated by "validators," and others of that ilk are being
seriously traumatized and that the physician has played a role in
contributing to such trauma. I am not suggesting that physicians break
the law. I am only suggesting that they take the time to get more
information before making such referrals. I am also pointing out the
common ineptitude of those people to whom they are referring their
patient for the "final decision."
Physicians must also appreciate how their "impressions" and statements
(for example, "consistent with sex abuse"), although not conclusive in
their minds, are interpreted by many lay people as the final "proof." In
many cases "consistent with sexual abuse" becomes transformed into
"physical evidence of sexual abuse." Perhaps if physicians appreciated
this more, they would be less quick to come to conclusions.
The measurement of the hymenal orifice is considered an important part
of the physical examination of girls suspected of being sexually abused. It
is important to appreciate how variable this finding can be. It differs
according to the examination technique used (McCann, Voris, Simon, &
Wells, 1990). Yet, there are people who are in jail because of this one
measurement. The horizontal (transverse) diameter of the hymenal
orifice is usually measured in the supine frog-leg position. Many factors
are operative in determining what this diameter is. If the child is correctly
positioned, the heels will be placed just below the buttocks. Clearly, if
they are in another position, such as 12 inches below the buttocks, a
different measurement will be obtained.
The examiner must be sure that the child's heels are at the same position
assumed by those children on whom the normative data were obtained.
Then there is the variable of the degree to which the child's legs are
spread. Usually, an assistant stands next to the child and slowly spreads
the child's legs while distracting and reassuring the child. Obviously, the
greater the degree of spread, the wider will be the hymenal orifice.
However, even when the legs are extended to the most extreme position
that is comfortable, the labia majora are usually still so close to one
another that the hymen will not be observable. Accordingly, the assistant
generally pulls the labia majora apart laterally and posteriorly in order to
allow hymenal visualization.
Obviously, there are varying degrees of such posterolateral traction, and
the greater the traction, the greater the expansion of the hymenal orifice.
Therefore, the assistant must attempt to apply such traction to the same
degree applied by those collecting the normative data. A common
standard is for the assistant to apply traction at the mid-point of the labia
majora to a point 1-1.5 cm on either side of the midline.
Furthermore, a lag must be allowed between the time of retraction and
the time of taking the measurement. There is usually a 1-2-second period
during which the hymenal ring must be allowed to dilate. Competent
examiners usually allow at least a 3-4-second time lag in order to ensure
that the hymenal ring is going to relax into its resting position. McCann
(1988) and McCann, Voris, Simon, & Wells (1990) emphasize that the
greater the traction on the labia majora, the greater the width the
hymenal diameter will be, and this is one of the explanations for why
different examiners get different results when measuring hymenal
openings. They also point out that the vertical diameter is smaller in the
supine frog-leg position than it is in the prone knee-chest position.
A small millimeter ruler is then placed very close to the vaginal opening.
Obviously, any squirming by the child is going to compromise the
accuracy of this measurement. However, even under optimum
conditions, and even with strict reproduction of the positioning used by
those collecting the normative data, there is bound to be some variability
of measurement because of the minuteness of the measurement being
considered here. A millimeter is approximately 1/25 of an inch. Although
the human eye is capable of discriminating between, let us say, 4 mm and
5 mm, it is obvious we are dealing here with a discrimination that is close
to the edge of the capability of the human eye (and brain). One has to
consider also that the distance of the examiner's eye from the hymenal
orifice and the distance of the ruler from the hymenal orifice can very well
affect the measurement perceived by the examiner.
I am convinced that if the same examiner were to examine the same child
on the following day, even when attempting to reproduce exactly the
conditions of the examination, there would be variability. Furthermore,
another examiner, again under the same circumstances, is also likely to
come up with a different measurement. The American Academy of
Pediatrics (1991) in its statement, "Guidelines for the Evaluation of Sexual
accused).
The McCann et al. study directs itself, as well, to the frequency of other
"abnormalities" sometimes considered manifestations of sex abuse.
For example,
he found labial adhesions to be present in 38.9% and periurethral bands
in 50.6% of the children studied.
He found erythema of the vestibule to be present in 56% of the children
examined.
(The vestibule is the portion of the vulva bounded by the labia minora. At
the floor of the vestibule are [from anterior to posterior] the clitoris,
urethral orifice, and the hymen.)
As mentioned previously, vulval rashes are quite common in children.
These relate to poor hygiene, a wide variety of infections (not necessarily
related to sexually transmitted diseases), tight panties, certain soaps,
rubbing, scratching, and masturbation (to mention the most common). I
have been involved in a number of cases in which these more common
and likely causes of the erythema were ignored and the examiner
concluded that the findings were "consistent" with sex abuse or even
manifestations of sex abuse.
I have discussed in some detail the McCann, Wells, Simon, and Voris
(1990) research because it provides compelling evidence that normal
children exhibit a wide variety of variations, many of which have been
considered signs of sex abuse. It is of interest that McCann et al.'s
original group consisted of 114 girls, but 23 were excluded because of the
early onset of puberty and the possibility of undetected sexual abuse.
The list of behavioral manifestations that warranted their exclusion from
the study included nightmares, fears, moodiness, change in school
performance, truancy, and acting out behaviors (among others). All of
these could be seen in normal children (at least on occasion), and many of
these behaviors are manifestations of a wide variety of childhood
problems completely unrelated to sex abuse. There are sexually abused
children, however, who may exhibit one or more of these behavioral
manifestations.
To the best of my knowledge, McCann et al. did not conduct a detailed
inquiry regarding whether these behavioral manifestations were signs and
symptoms of sex abuse, were in the normal range, or related to other
causes. On the one hand, the exclusion of all these children, simply on
the basis of the presence of one or more of these symptoms, made his
sample "purer" thereby lessening the likelihood that sexually abused
children were included. On the other hand, he may have unnecessarily
group than in the abused group (68% vs. 34%, p < 0.0001). There was no
statistical difference between the dimensions of the hymenal opening of
the abused and the non-abused group. One would certainly expect a
larger average hymenal opening in the abused group, but this study did
not confirm such a difference. Perhaps there were too few girls in the 119
abused who had the kind of sexual molestation that would produce an
enlargement of the hymenal ring.
However, as Herman-Giddens and Frothingham (1987) point out,
"The hymen, contrary to common notion, is often a slack, thick, folded,
stretchable tissue which may persist after digital or penile penetration."
The same authors hold that
"a vaginal opening of greater than 5 mm is not common and may indicate
vaginal penetration with a finger, object, or penis."
McCann (1988) states that 85% of preadolescent children who are being
molested are molested on a chronic, ongoing, and recurring basis. Such
molestation should, then, produce changes indicative of chronic trauma.
He emphasizes the importance of examination for bruises in other parts of
the body, in the nongenital area. The mouth is a common site of lesions
because the perpetrator may have placed his hand over the child's mouth
in order to stop the child from screaming. Grab marks on the arms and
inner thighs are also strongly suggestive of sex abuse, especially thumb
marks on the inner aspect of the thigh, placed there when the child's legs
were forced apart.
McCann (1988) also observes that labial injury is common at the
time of rape because the labia majora are generally closed and
the perpetrator pushes his penis repeatedly against closed labia.
He believes that the most common area of hymenal injury is
between the 4:00 and 7:00 o'clock positions because the penis is
forced downward and backward. He emphasizes that children
heal quickly and that examinations after the first few days may
not confirm the abuse. Because the length of the vagina of fourand five-year-old girls is only 4 cm, trauma to the vagina, cervix,
and lower part of the uterus is common.
McCann, Voris, and Simon (1988) studied six sisters, all of whom had been
sexually molested by male family members. All of these girls had labial
adhesions, and four of the six had changes in the area of the posterior
fourchette (a fold of mucus membrane just inside the posterior
commissure of the vulva). Furthermore, four of the girls' hymens revealed
abnormalities of the hymenal edge (irregular, rolled, or septum) and three
revealed irregularities of the hymenal membrane (redundant, thick,
scarred). Four exhibited abnormal vascular patterns, and all six exhibited
Normal-appearing genitalia.
2.
Nonspecific findings.
Abnormalities of the genitalia that could
have been caused by sexual abuse, but
also are often seen in girls who are not
victims of sexual abuse (e.g.,
inflammation and scratching). These
findings may be the sequelae of poor
perineal hygiene or nonspecific infection.
Included in this category are redness of
the external genitalia, increased vascular
pattern of the vestibular and labial
mucosa, presence of purulent discharge
from the vagina, small skin fissures or
lacerations in the area of the posterior
fourchette, and agglutination of the labia
minora.
3.
Specific findings.
The presence of one or more
abnormalities strongly suggesting sexual
abuse. Such findings include recent or
healed lacerations of the hymen and
vaginal mucosa, enlarged hymenal
opening of 1 cm, proctoepisiotomy (a
laceration of the vaginal mucosa
extending through the rectovaginal
septum to involve the rectal mucosa),
and indentations in the skin indicating
teeth (bite) marks. This category also
includes patients with laboratory
confirmation of a venereal disease.
4.
Definitive findings.
Any presence of sperm.
Paul (1977, 1986) claims that penile penetration in younger children will
cause widespread injuries, including lacerations of the hymen, vagina,
and labia. There will be profuse bleeding and the child will experience
excruciating pain. This is an important point because in many cases of
fabricated sex abuse, the child will describe no pain or minimal pain.
Anal Findings
McCann (1988) observes that children who have been subjected to anal
intercourse on repeated occasions suffer with a relaxation of the external
anal sphincter, but not of the internal anal sphincter. Accordingly, there is
a typical funnel-like appearance of the anus on physical examination.
Finkel (1989) reports on seven children who had experienced acute
genital and anal trauma in association with sexual abuse. Some of the
more superficial manifestations of the trauma (abrasions, superficial
lacerations, contusions, and bleeding) were not apparent after four days.
In two of Finkel's seven cases, penile-anal penetration was involved. In
one case, Finkel described "superficial lacerations of the anal verge
tissues in anterior and posterior midline positions each measuring 2 mm
circumferentially and 3 mm in length." In the second case he described
five mucocutaneous superficial lacerations, some of which extended from
the external anal mucosa down into the anal canal.
Paul (1990) observes that, even with the use of a lubricant, penile
penetration of the anus will almost invariably result in some injury to the
anal verge. He stresses the importance of the history, from the child, of
severe pain not only during the abuse, but when the child next
attempts to have a bowel movement. He states: "This exacerbation of
pain on defecation is an almost invariable 'story' and is so impressed on
the child's mind that it is rarely forgotten" (p. 6).
Sexually Transmitted Diseases
The presence of a sexually transmitted disease (previously referred to as
venereal disease) is generally considered definitive evidence for sex
abuse. Of the wide variety of such diseases, the most commonly found in
sexually abused children are gonorrhea, syphilis, Chlamydia, condyloma
acuminatum, Trichomonas vaginalis, and herpes 1 (genital). However, it
is important to appreciate that gonorrhea, syphilis, and Chlamydia can be
acquired perinatally from the mother, and this must be given
consideration before deciding that the presence of such a disease
automatically indicates sex abuse (American Academy of Pediatrics,
Committee of Child Abuse and Neglect, 1991).
The material for gonorrhea culture is generally obtained from cotton
swabs of the vagina, throat, and rectum. The organism may sometimes
be grown from cultures of the urine of suspected boys. The urine can also
be examined for Trichomonas infection. Tests for syphilis are usually
obtained from a blood sample. Vaginal secretions can also be cultured for
the presence of Chlamydia, herpes, and Trichomonas. Vaginal secretions
can be examined directly (microscopically, with proper staining) for
gonorrhea and Trichomonas.
Condyloma acuminatum is also referred to as genital warts and venereal
warts. It is caused by a virus called the human papilloma virus (HPV). It
is the most common viral sexually transmitted disease in the United
States and is now more common than herpes (due to the recent rapid
increase in its incidence). Because the incubation period is approximately
one month (Stewart, Stewart, Guest, & Hatcher, 1987), the genital warts
will not be observable immediately after a child has been abused. The
diagnosis is made generally by direct observation, the warts usually
appearing like warts on other parts of the body, but they do extend into
the vaginal canal, cervix, and rectum. Sometimes the warts are
inconspicuous or completely invisible to the naked eye. Horowitz (1987)
provides an excellent protocol for the examination for sexually
transmitted diseases.
Although the presence of a sexually transmitted disease is strongly
suggestive of sex abuse, the disease may have been acquired by the child
in a nonsexual way. The problem in such situations is that the suspect
may also have the sexually transmitted disease but did not have a sexual
encounter with the child. Rather, the disease was transmitted
nonsexually. Clearly, an accused who is trying to deny a sexual encounter
will give strong support to this theory.
Support for this can be found in the medical literature, where there are
many articles providing instances of just such a method of transmission.
For example, Shore and Winklestein (1971) claim that 50% of their sample
of children contracted their gonococcal infection in the absence of sex
abuse and that only one-fifth acquired the gonorrhea through a sexual
experience. Kaplan (1986) claims that the gonococcus can survive
outside the human body for up to 24 hours and cites a 1929 study in
which several newborns in the same hospital nursery were found to have
gonococcal infections. It was believed that the organism was transferred
with thermometers. Wakefield and Underwager (1988) refer to studies in
which gonorrhea was found to have been transmitted nonsexually among
peers, via close physical contact with infected adults or indirect contact
through bedclothes or hands. They also refer to the work of DeJong et al.
(1982), who report that venereal warts can be transmitted through close
nonsexual contact, during delivery, and by sexual encounters.
Sperm in the Vagina and the Pregnancy Test
Link Bar 0
References
American Academy of Pediatrics, Committee on Child Abuse and Neglect
(1991). Guidelines for the evaluation of sexual abuse of children.
Pediatrics, 87, 254-260.
Behrman, R. E., & Vaughan, V. C. (1983). Textbook of Pediatrics
Philadelphia: W.B. Saunders Co.
DeJong, A. R., Weiss, J. C., & Brent, R. L. (1982). Condyloma acuminata in
children. American Journal of Diseases of Children, 136, 704-706.
Emans, S. J., Wood:. B. R., Flagg, N. T., & Freeman, A. (1987). Genital
findings in sexually abused, symptomatic and asymptomatic girls.
Pediatrics, 79, 778-785.
Finkel, M. A. (1989). Anogenital trauma in sexually abed children.
Pediatrics, 84, 317-322.
Goff, C. W., Burke, K. R., Rickenback, C., & Buebendorf, D. P. (1989).
Vaginal opening measurement. American Journal of Diseases of Children,
143, 166-168.
Herman-Giddens, M. B., & Frothingham, T. B. (1987). Prepubertal female
genitals: Examination for evidence of abuse. Pediatrics, 80, 203-208.
Hobbs, C. J. & Wynne, J. M. (1986). Buggery in childhood: A common
syndrome of child abuse. Lancet, 2(8510), 792-796.
Hobbs, C. J., & Wynne, J. M. (1987). Child sexual abuse: An increasing rate
of diagnosis. Lancet, 2(8563), 837-841.
Horowitz, D. A. (1987). Physical examination of sexually abused children
and adolescents. Pediatrics in Review, 9(1), 25-29.
Kaplan, J. M. (1986). Pseudoabuse the misdiagnosis of child abuse.
Journal of Forensic Science, 31, 1420-1428.
McCann, J. (1988, January 21). Health science response to child
maltreatment conference. San Diego, CA.
McCann, J. (1990). Use of the colposcope in childhood sexual abuse
examinations. Medical Clinics of North America, 37(4), 863-880.
McCann, J., Voris, J., & Simon, M. (1988). Labial adhesions and posterior